The healthcare industry is undergoing a period of rapid technical and clinical innovation as it moves away from episodic, reactive care.
While data-driven decisions and holistic approaches to patient management can bring significant benefits, these new strategies are also creating a mounting problem: physician burnout is increasing at an alarming rate.
Physician burnout is a problem at 83 percent of healthcare organizations, according to a 2018 survey published in the New England Journal of Medicine Catalyst.
The Agency for Healthcare Research and Quality (AHRQ) defines physician burnout as “a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment.”
As these feelings of burnout fester, they seep into the patient-provider relationship and erode the patient experience.
“The problem with physician burnout is that it leads to worse quality care,” John Cullen, MD, the president of the American Academy of Family Physicians (AAFP), said in an interview with PatientEngagementHIT.com.
Part of minimizing burnout is recognizing the value that physicians bring in to organizations, financially and otherwise.
Physicians that do not feel engaged by their places of employment are more likely to be disaffected - and may, in turn, be more likely to retire earlier or seek non-clinical roles. The resulting exodus from clinical practice is anticipated to have a major negative impact on access to care.
And when doctors do stay with their jobs in the medical field, the quality of care declines, putting patients in jeopardy. Burned out physicians are at elevated risk of errors that could result in patient safety concerns, research has shown.
At the root of the physician burnout issue is the seemingly never-ending to-do list doctors face each day. In addition to traditional clinical tasks, new payment models have introduced a litany of administrative and documentation demands.
Rather than focusing on the clinical duties and patient relationships that have long characterized the medical profession, doctors are being forced to spend hours each day working with EHRs to meet documentation requirements. Physicians employed in larger health systems may also face additional burdens related to system-level quality and performance.
“For family physicians, working for a health system is one of the risk-factors for burnout, more so than being in an independent practice,” Cullen explained. “A lot of that comes from administrators not understanding what patient care is about, and really demanding that family physicians do things that are really not where our skills are best used.”
“What we should be doing is working with patients. That's what we've been trained to do and why we went into medicine.”
Although Cullen speaks for his own specialty of family medicine, the importance of having enough time to develop meaningful relationships with patients rings true for nearly all doctors.
The 2018 Biennial Survey of America’s Physicians from the Physicians Foundation revealed that good patient relationships are the greatest source of job satisfaction for 79 percent of physicians.
Doctors come to medicine to treat patients. The grueling process of medical school, internships, residency, and continuing medical education all become worth it when a doctor can improve the quality of life for another human being.
It’s worth it for the patient, too. Individuals seeking care do not want to interact with a physician who is distracted, unhappy, or simply too exhausted to have a real conversation about issues that impact the patient’s quality of life.
“As doctors being having difficulties with burnout, they have poorer patient interactions because doctors do not have the emotional bandwidth to communicate with patients in an empathic way. And patients feel it,” Cullen said.
Eliminating physician burnout is, therefore, not just an issue for the human resources department. Burnout is a patient engagement killer, and preventing disaffection from poisoning the patient experience is a key concern for health system leaders and industry policymakers.
Helping physicians maintain their empathy
Between analyzing patient data, checking the boxes of the EHR, adhering to Medicare or other payer standards, and fulfilling hospital or local physician group standards, doctors are left with comparatively little time to see their patients.
In the primary care environment, physicians may spend six hours a day on entering data into the EHR, the American Medical Association says. That’s more than half of the typical 11.4 hour workday for a physician, which already exceeds the amount of time most other workers spend at their jobs.
Providers who reduce their patient face-time further may be more able to keep up with their paperwork, but are actually risking an increase in stress, says Cullen.
“Spending less time with patients to deal with administrative tasks further pushes doctors into that cycle of increasing burnout,” Cullen said. “Conversely, having positive patient interactions really helps open physicians up so that they have more positive interactions in the future.”
Burnout results in a loss of empathy with patients that can have dangerous consequences for both participants in the relationship, he explained.
“In part, burnout is a clinical depersonalization where one has difficulty reacting to patients with as much empathy as he needs. From a primary care perspective, that sense of empathy is so incredibly important,”
“If we see patients and we're not empathetic, then they're actually not going to do as well,” he continued. “There's something about the physician-patient interaction where empathy plays a really key role. We have a tendency to think of illnesses being a problem that needs fixing, and the physician is the repairman. But it’s a lot more complicated than that.”
Cullen suggests that physicians take time throughout the day for self-care and self-reflection - even if it’s only a few moments here and there during breaks in the schedule.
“Just the act of washing your hands in between patient encounters should be a mindfulness exercise,” he stated.
“It is a way of resetting emotionally. It’s almost like there's an emotional contagion that you can bring from one room to the next, and washing your hands helps cleanse your mind of that. I've certainly seen that when I go through very intense visits, emotionally. If I'm not careful, I can carry that into the next room. And so washing my hands in between patients is a mindfulness exercise.”
Addressing burnout through organizational policies
Organization leaders also have a role to play in addressing physician burnout and its impacts on patient care. Currently, doctors and hospital or practice administrators are not always on the same page about physician workloads, Cullen suggested.
Administrative leaders are focused on fulfilling certain clinical quality metrics, using patient data to curb costs where possible, and transitioning to value-based care models. These priorities are not necessarily a bad thing. They are all central to a hospital administrator’s job and are critical for keeping a practice or health system afloat.
But administrative goals don’t always align with clinical realities, which can in turn create physician burnout. When leadership loses sight of doctors’ responsibility to create positive patient interactions, it can push physicians to disengage from their work.
Hospital and practice administrators have a responsibility to create policies and cultural expectations that allow employees to work to their fullest capacity without driving themselves into an emotional crisis.
Practices that give physicians the resources to make their jobs easier and the benefits that allow them to recharge will likely see lower rates of physician burnout than those that do not, according to Cullen.
“Making sure that everybody feels valued is really important, and even little things go a long way in that regard,” he asserted.
“Just finding out, for example, what people need, what would make their job easier, and then making sure there's enough time for people to go on vacation, exercise, and get enough sleep, is key,” he continued.
“A lot of family physicians are spending two or three hours a night before going to bed just completing the charts they have opened during the course of the day. That's really detracting from family time, which is really important to prevent burnout because you need to have those relationships.”
Additionally, healthcare organizations can establish team-based care models to maximize their existing resources, according to Jack Stockert, MD, the managing director of Strategy and Business Development at Health2047.
Team-based care models tap physician assistants, nurse practitioners, medical assistants, and other relevant personnel to share responsibilities and allow all clinicians to work to the top of their skill sets.
“How do we move some of those things off the plates of physicians? What does it mean to be 100 times more productive as a physician?” Stockert posited. “That's not seeing another two, three, four, five patients in the day. It's really contemplating a breakthrough in workflows, an ability to let clinicians practice in the highest clinical acuity, and embracing the abilities of those around them.”
When a medical assistant takes on the many administrative tasks she is qualified to address, it frees up physicians to focus on complex clinical problems while building the meaningful relationships they want with their patients.
When designing a team-based care model, organizational leaders should consider which tasks non-physician clinicians will assume and the extent to which physicians will supervise personnel, Cullen recommended.
It is important to note that burnout is an issue that impacts all members of a care team: nurses, physician assistants, and medical assistants all also experience burnout, and organizations need to be careful not to duplicate the problems physicians are currently facing.
Ensuring technology does not create barriers to relationship-building
At the root of many of physicians’ problems is the onslaught of clinical quality measures, nearly every expert agrees. Survey after survey reveals that physicians spend too much time documenting and it is impacting their job satisfaction.
“We're spending almost two for one right now doing administrative work behind the scenes, so two hours for every one hour of patient care,” Cullen said. “And that's something that has significantly increased over the last few years, mainly with the introduction of electronic health records, unfortunately.”
Consequently, that computer has literally and figuratively gotten in between the physician and the patient, hurting patient satisfaction.
The healthcare industry as a whole can address this by rethinking clinical quality measures, Cullen said.
“One of the issues that we're dealing with is the extreme amount of work that we need to do in order to get things done for our patients,” Cullen stated.
Documentation for clinical quality measures is a significant part of value-based care, but it’s getting in the way of physicians delivering patient-centered care, Cullen pointed out. Doctors who are too focused on documentation are missing out on patient interactions, and could even miss an important part of that patient’s diagnosis or clinical care.
Unfortunately, this is not an area doctors themselves can control. They are beholden to whatever measures different payers, including Medicare and Medicaid, may want from them.
But payers and policymakers are starting to take these provider demands into account. CMS, for example, has been hard at work to simplify provider documentation.
The Meaningful Measures initiative, announced in the fall of 2017, aims to look at clinical quality measures most relevant to improving patient care. The 2019 Physician Fee Schedule (PFS) will streamline evaluation and management (E&M) measures that many provider groups said were burdensome.
But reducing the number and complexity of quality measures is only a first step. The industry must address the fundamental problems of the electronic health record, Cullen said.
“Electronic health records still just don't work very well,” Cullen stated. “They’re improving, but the problem is that electronic records, by and large, are kind of check boxes. And that's really not how we interact with patients. It's much more of a holistic, empathetic interaction, and it needs to be in order for us to do our job. It's hard to translate that into an electronic record.”
The EHR also does not do a good enough job with presenting the information physicians need, when they need it, Health2047’s Stockert added.
Between the clunkiness of the interface and the data that is buried within it, doctors need to spend time clicking through the EHR before they can begin getting to the crux of the patient encounter.
“Part of the issues inside those systems are that they need to enable new types of interfaces for clinicians to see exactly what they need for this patient in the moment they’re walking in to see that patient,” he said.
“Right now, doctors have to spend 10 minutes going around the EHR to find that information. What a doctors needs is different for one patient than if they’re going to see a patient with different issues or different conditions.”
Clinical quality reporting may be outside of any one organization’s control, but the EHR isn’t. The vast majority of EHR systems allow for significant customization and optimization.
Organizations that bring clinical users to the table when designing new workflows are likely to see the greatest downstream success, Stockert said.
“The best innovations are dreamed up by the people who will end up using them,” Stockert asserted. “They're the ones with the pain points, they're the ones with the use cases.”
“As we move beyond this first and second inning of EHRs as administrative tools, as we've now started to shine a light on the power of the right clinical decisions actually impacting business in a positive way, we need to more effectively empower the right clinical decisions. And to do that, clinicians should be encouraged to help dream the visions of what is possible.”
Cullen agreed, sharing the EHR features he believes would improve his own practice and reduce physician burden.
Next, clinical decision support systems need reworking. While these tools are an integral part of the EHR, clinical decision supports should be more discrete and integrate into the technology to prevent alarm fatigue.
Finally, a tool that creates a care team to-do list—without requiring literal check-boxes or creating alarm fatigue—would help enable team-based care, Cullen said.
Efforts to address the physician burnout problem are fledgling, and as industry leaders consult different solutions to burnout, they must consider which are most beneficial and feasible for specific physician needs.
Ultimately, these solutions need to focus on putting patient care at the forefront. Reducing physician burnout will require allowing doctors to do what they do best: treating patients.